Clear Form Print Form Fax to: ASIFlex (877) 879-9038 *No Cover Page Required* Dependent Care/ Health Care Reimbursement Account Plans CLAIM FORM – PLAN YEAR 201__ Page 1 of ____ NAME: (Please Print) Campus Social Security Number Street Address City, State, Zip Telephone Number Dependent Care Reimbursement Account (DCRA) Dependent care expenses must be for a dependent who is incapable of self care or under the age of 13 at the time the care was provided. Name of Dependent Age Date(s) Care Provided From To* Name, Address, and Taxpayer Identification Number of Care Provider Cost for Care Period ASIFlex use only 0.00 Total Dependent Care Amount Requested I provided the dependent care as stated above. __________________________________________ __________ _______________ Care Provider's original signature Date SSAN/Tax ID# *Claims for future services are not eligible for reimbursement. Health Care Reimbursement Account (HCRA) Date Medical Care Provided (Arrange documentation in same order) Name of Medical Provider General Medical Expense Description. Include medical condition for over-the-counter items. Patient Name Total Medical Amount Requested Relationship Amount that is your responsibility ASIFlex use only 0.00 Please submit a DETAILED STATEMENT OF SERVICES or INSURANCE EXPLANATION OF BENEFITS (EOB) statement for each expense you are claiming. Credit card receipts or statements with a previous balance are not sufficient documentation. As a participant of the Plan, I certify that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while I was covered under my employer's Flexible Spending Plan and that the expenses have not been reimbursed and reimbursement will not be sought from any other source. Any claimed Dependent Care Assistance expenses were provided for my dependent under the age of 13 or for my dependent who is incapable of self care. I fully understand that I am fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim, and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, I may be liable for payment of all related taxes including federal, state, or local income tax on amounts paid from the Plan which relate to such expense. __________________________________________________ Employee's Signature _________________________________ Date ASIFlex P. O. BOX 6044 COLUMBIA MO 65205-6044 Submit Form to ASIFlex ALONG WITH SUPPORTING DOCUMENTATION Web site: http://www.asiflex.com Online Claims Submission https://my.asiflex.com Toll-free fax (877) 879-9038 Claim Filing Requirements 1. Print your name, address, and social security number. 2. List expenses by date & arrange the supporting statements in the same order. Please circle the service dates on your documentation. If you have several statements from the same provider, you may subtotal them and list them on one line with a range of dates. Day care claims - complete the DCRA section Health care claims - complete the HCRA section (The amount column should be the amount you are requesting after any insurance payment or provider discount for each expense). 3. Enclose required documentation*. A written statement from the dependent care or medical (Dr., hospital, pharmacy, etc.) provider of the service or an insurance company benefits statement showing all of the following: The name of the dependent care or medical service provider, The date or range of dates of medical service or day care. Although this date may be the same as the date paid it must be clear on what date the service was provided. The services must have already been provided. A description of the service provided (for example, for health care, "dental cleaning", or for day care "day care"), The name of the person or persons receiving the medical or dependent care, and The cost of the service, not just the amount paid. *Dependent Care claims only” - You may either provide documentation from the day care provider or have the provider complete the DCRA, then sign on the "Provider's Signature" line and date the signature. You do not need to do both. Requests filed without the above documentation cannot be processed and will be returned. 4. Sign the claim form. 5. Keep copies for your tax records. 6. Mail to the address on the front of this form, submit the claim online, or Fax to (877) 879-9038. This is a toll-free number but employee use of an office fax machine may not be appropriate. Please check with your employer before using an office fax machine. Online Claims Submission: In order to submit claims online, you must 1) have high-speed internet access, 2) be able to scan your supporting documentation into one or more PDF files that are less than 812K (8MB) in size each, and 3) know your P.I.N., which you can find on your enrollment confirmation, or you may obtain by calling ASIFlex’s customer service center (800) 659-3035. The website for online claims submission is https://my.asiflex.com. Emailed claims will not be accepted. Over-the-counter medicines & drugs: Effective January 1, 2011, over-the-counter (OTC) medicines will not be reimbursable unless you have a valid prescription. Insulin still qualifies for reimbursement without a prescription. Equipment, supplies, and diagnostic devices such as bandages, hearing aid batteries, blood sugar test kits, etc. will remain eligible for reimbursement without a prescription. Please refer to ASIFlex’s website, http://www.asiflex.com, for a list of OTC medicine categories that no longer qualify for reimbursement without a prescription after January 1, 2011. To claim vitamins, herbs or nutritional supplements, you must have a written diagnosis of the medical condition and “prescription” of all specific items for that condition on file with the claims office. You must renew this physician notice every 12 months and file it with the claims office with the first claim submitted for those items each plan year. Orthodontics: Requests may be reimbursed for a reasonable monthly payment on or after the payment is due and paid. The payment must be a reasonable approximation of the value of each month's service. You may only file claims for orthodontic payments while treatment is in process. You must submit a paid receipt from your orthodontist or a photocopy of the monthly coupon and your check. Pre-payments are not allowed. You must submit a written statement from the orthodontist showing the charge for the initial installation work, when it was completed and a paid receipt to claim an initial down payment or appliance fee. Medical equipment: Requires a letter from a physician every 12 months stating the nature of your medical condition, the specific equipment needed and that the equipment is essential to the treatment. Claim forms: You may copy this form or obtain forms online at http://www.asiflex.com Claims payment and account information is available 24 hours a day 7 days a week: View complete history including available funds online at www.asiflex.com (Account Detail). You will need your P.I.N., which you can find on your enrollment confirmation, or you may obtain by calling ASIFlex’s customer service center (800) 659-3035. Resources Customer Service: Customer Service Email: Online claims submission: (800) 659-3035 asi@asiflex.com https://my.asiflex.com Toll-Free Claims Fax: Customer Service Website: Claims mailing address: (877) 879-9038 www.asiflex.com P.O. Box 6044 Columbia, MO 65205